All Reports

Date Issued
|
Report Number
23-00017-81
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Topics: Mental Health,Patient Care Services Operations,Suicide Prevention
Related Media: Facility Photo

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Director ensures Supply Chain Management, Engineering, or Facility Management Service staff monitor temperature and humidity in all clean and sterile storage rooms to maintain a stable environment.

No. 2
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to Veterans Health Administration (VHA)

The Executive Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.

No. 3
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to Veterans Health Administration (VHA)

The Executive Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
23-00010-84
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Topics: Patient Safety,Suicide Prevention

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff keep areas used by patients clean and orderly.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff store clean and dirty equipment and supplies separately.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Associate Director ensures staff place all examination tables with the foot facing away from the door.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.

Date Issued
|
Report Number
23-00153-41
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Topics: Claims and Fiduciary

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No. 1
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)

Conduct a review of the convalescence claims for hip and knee replacements and resurfacing completed from February 7, 2021, through August 31, 2022, and take appropriate actions to correct convalescence periods and ensure monetary benefits are accurate.

No. 2
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)

Implement a plan to assist employees with determining the effective date, incorporating the initial month under 38 C.F.R. § 4.30, and calculating the duration of convalescence.

No. 3
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)

Develop implementation procedures to include monitoring the accuracy of claims processing when the related rating schedule has been revised.

No. 4
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to Veterans Benefits Administration (VBA)

Supplement training on the rating schedule updates to include how to apply the changes to help ensure comprehension.

Total Monetary Impact of All Recommendations
Open: $ 3,300,000.00
Closed: $ 0.00
Date Issued
|
Report Number
22-04038-82
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Topics: Suicide Prevention
Related Media: Facility Photo

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

Date Issued
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Report Number
22-02113-75
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Topics: Care Coordination,Community Care,Suicide Prevention

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The North Las Vegas VA Medical Center Director reviews the community care coordination program, identifies deficiencies, and takes actions as warranted to ensure compliance with the Veterans Health Administration Field Guidebook, including training and completion of all care coordination responsibilities for patients discharged from a community hospital stay paid for by the VA.

No. 2
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to Veterans Health Administration (VHA)

The North Las Vegas VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the primary care processes, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including response time to patients’ scheduling requests and availability of same-day access for face-to-face and telephone encounters.

No. 3
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to Veterans Health Administration (VHA)

The Sierra Pacific Network Director in conjunction with the Chief Medical Officer continues the review of the complete course of care provided by the Veterans Integrated Service Network physician for the patient, including the delivery of anticoagulants, and ability to access scanned documents in the electronic health record, and takes actions as warranted.

No. 4
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to Veterans Health Administration (VHA)

The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief and the Primary Care Service chief, review the suicide prevention training program to ensure compliance with Veterans Health Administration policies, including reporting requirements following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.

No. 5
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to Veterans Health Administration (VHA)

The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief, reviews the suicide prevention coordinators’ compliance with Veterans Health Administration policies, including actions required to complete a behavioral health autopsy and family interview tool contact form following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.

Date Issued
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Report Number
23-01198-47
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Topics: Financial Management

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Ensure that healthcare system finance office staff are made aware of all VA financial policy requirements in the review and management of inactive open obligations and deobligate any identified excess funds.

No. 2
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to Veterans Health Administration (VHA)

Ensure cardholders comply with VA financial policy record retention requirements.

No. 3
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to Veterans Health Administration (VHA)

Establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.

No. 4
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to Veterans Health Administration (VHA)

Establish local processes and procedures to ensure the routine scanning of inventory items, as well as monitoring of all inventory data, so that performance measures are maintained.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Ensure supply chain managers implement a plan to train staff to promote the standardization of supply chain duties and to correct data validity issues within inventory systems.

No. 6
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to Veterans Health Administration (VHA)

Ensure the chief of supply chain services conducts and documents quarterly physical inventory memoranda of “A” classified items in accordance with Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Ensure the chief supply chain officer reviews the edit access list for the facility item master file, and a process is put in place to document this review, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Develop a plan to align inventory management practices, such as ABC inventory analysis methodology, with Veterans Health Administration policy.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.

Total Monetary Impact of All Recommendations
Open: $ 20,071,200.00
Closed: $ 0.00
Date Issued
|
Report Number
23-00011-73
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Topics: Medical Staff Privileging Credentialing,Patient Safety,Suicide Prevention
Related Media: Facility Photo

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs use service-specific criteria in the professional practice evaluations of licensed independent practitioners.

No. 2
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to Veterans Health Administration (VHA)

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations.

No. 3
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to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures the Comprehensive Environment of Care Coordinator schedules, and staff complete and document, environment of care inspections at the required frequency.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures appropriate personnel install over-the-door alarms for sleeping room doors in the mental health inpatient unit.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on sleeping room doors in the mental health inpatient unit.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures staff maintain a safe environment in the mental health inpatient unit.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures staff keep patient care areas safe and clean.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.

No. 10
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to Veterans Health Administration (VHA)

The Chief of Staff ensures the Suicide Prevention Coordinator conducts, tracks, and reports a minimum of five suicide prevention outreach activities monthly.

Date Issued
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Report Number
21-03255-02
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Topics: Contract Integrity

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No. 1
Open Recommendation Image, Square
to Office of the Secretary (SVA)

Mediate the two offices’ collaboration to develop and publish updates to the personnel security policies and procedures for vetting contractor employees to include appropriate roles and responsibilities; standard contract language to communicate the requirements for vetting contractor employees, including whether a fingerprint check or background investigation is required, that can be used across the department; and a requirement that the VA organization requesting a contract provide the position designation record in the acquisition package submitted to the contracting office.

No. 2
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to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Perform and document compliance inspections of the procedures for vetting contractor employees and the issuance of VA identification credentials at medical facilities supported by Network Contracting Office 23, including the St. Cloud VA Medical Center.

No. 3
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to Acquisitions, Logistics, and Construction (OALC)

Update and publish the Veterans Affairs Acquisition Regulation and Veterans Affairs Acquisition Manual to direct the department’s acquisition professionals to the correct guidance for vetting contractor employees, which should include VA’s personnel security and suitability program policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)

Update and publish or rescind Acquisition Policy Flash 16-13, “Use of VA Handbook 6500.6, Appendix A, Checklist for Information Security in VA Service Acquisitions,” to ensure VA acquisition professionals understand that VA Handbook 6500.6 is not the only personnel security policy they must comply with.

No. 5
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to Information and Technology (OIT)

Update and publish VA Handbook 6500.6, Contract Security, in collaboration with the Office of Acquisition, Logistics, and Construction and the Office of Human Resources and Administration/Operations, Security, and Preparedness, including retitling it to better correspond to its content and removing any personnel security steps that should only be discussed in VA personnel security and suitability program policies.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Review the actions of the officials responsible for planning, awarding, and administering contract 36C26320A0021, which included vetting procedures that did not comply with federal or VA policies, and take administrative action if appropriate.

Date Issued
|
Report Number
22-04134-63
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Topics: Clinical Care Services Operations,Medical Staff Privileging Credentialing,Mental Health
Related Media: Facility Photo

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff keep all areas clean and safe.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff keep the medical center well maintained.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Pharmacy Services limits medication access to approved staff members.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff store sterile supplies in temperature- and humidity-controlled storage rooms.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures providers notify the suicide prevention team of patients who report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

Date Issued
|
Report Number
23-00005-62
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Topics: Clinical Care Services Operations,Medical Staff Privileging Credentialing,Mental Health
Related Media: Facility Photo

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff complete root cause analyses for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 2
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to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures external practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for practitioners in “two-deep” services or specialties.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Medical Center Director ensures the Safety and Occupational Health Specialist or designee tracks environment of care inspection deficiencies until they are resolved.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit at least quarterly.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures the Supervisory Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.

Date Issued
|
Report Number
22-02975-70
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Topics: Care Coordination,Patient Safety,Women’s Health

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Montana VA Health Care System Medical Center Director ensures that all providers, including the Chief of Staff, practice within their approved privileges.

No. 2
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to Veterans Health Administration (VHA)

The Under Secretary for Health ensures review of Veterans Health Administration maternity care directives to determine if more specific guidance on the limitations of pregnancy care at VA facilities is necessary to ensure that pregnant patients receive maternity care according to evidence-based practice standards, and ensures guidance is updated as warranted.

No. 3
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to Veterans Health Administration (VHA)

The Montana VA Health Care System Medical Center Director ensures adherence to Veterans Health Administration and facility policies for pregnancy care.

No. 4
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to Veterans Health Administration (VHA)

The Montana VA Health Care System Medical Center Director ensures subject matter expert review of endometrial ablation procedures performed by the facility Chief of Staff to determine whether standards of care were followed for clinical indications, patient selection, and preoperative evaluation for patients who underwent endometrial ablation, and determine whether clinical disclosures or additional patient follow-up is indicated.

No. 5
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to Veterans Health Administration (VHA)

The Rocky Mountain Network Director ensures processes are in place to support facilities’ external review process for ongoing professional practice evaluations in cases requiring external review by Veterans Health Administration policy and monitors compliance.

No. 6
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to Veterans Health Administration (VHA)

The Montana VA Health Care System Medical Center Director ensures adherence to all VHA and facility policies pertaining to privileging and re-privileging of providers including the Chief of Staff.

No. 7
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to Veterans Health Administration (VHA)

The Montana VA Health Care System Medical Center Director conducts a comprehensive review of the facility ongoing professional practice evaluation processes to ensure compliance with Veterans Health Administration and facility policy, and takes action as warranted.

No. 8
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to Veterans Health Administration (VHA)

The Rocky Mountain Network Director ensures a process is in place to monitor for timely completion of administrative actions for members of facility executive leadership team when appropriate, identifies noncompliance, and takes action as warranted.

No. 9
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to Veterans Health Administration (VHA)

The Rocky Mountain Network Director conducts a review of the state licensing board reporting processes at the facility to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.

No. 10
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to Veterans Health Administration (VHA)

The Montana VA Health Care System Medical Center Director considers subject matter expert findings from the retrospective review of care provided by the Chief of Staff, determines whether clinical or institutional disclosures or additional patient follow-up is indicated, and takes action as warranted.

Date Issued
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Report Number
23-01325-59
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Topics: Appointment Scheduling and Wait Times,Mental Health

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Oklahoma City VA Health Care System Director, in conjunction with Behavioral Health Service leaders, reviews the community care consult management and appointment scheduling processes, identifies deficiencies, and takes action as warranted.

Date Issued
|
Report Number
23-00009-57
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Topics: Mental Health,Patient Safety,Suicide Prevention
Related Media: Facility Photo

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff have written procedures for responding to utility system disruptions.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff identify, minimize, or eliminate safety and security risks in the physical environment.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

Date Issued
|
Report Number
22-00057-54
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Topics: Medical Staff Privileging Credentialing,Patient Safety
Related Media: Facility Photo

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Network Director determines the reasons for noncompliance and ensures the Patient Safety Officer collects, analyzes, and acts on peer review summary data.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials file and makes a recommendation on continuing the appointment process for physicians with a potentially disqualifying licensure action.

Date Issued
|
Report Number
22-04131-49
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Topics: Clinical Care Services Operations,Medical Staff Privileging Credentialing

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Central Texas VA Health Care System Director reviews the care provided to the patient by Nurse Practitioner 1 and Nurse Practitioner 2 and takes action as warranted.

No. 2
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to Veterans Health Administration (VHA)

The Central Texas VA Health Care System Director reviews the care provided by Nurse Practitioner 1 and Nurse Practitioner 2 as licensed independent practitioners to other urology patients, and takes action as warranted.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Central Texas VA Health Care System Director reviews the privileging and professional practice evaluation processes and performance indicators for nurse practitioners granted full practice authority in specialty care clinics to ensure compliance with current Veterans Health Administration policy and quality of care.

No. 4
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to Veterans Health Administration (VHA)

The Central Texas VA Health Care System Director ensures that facility leaders communicate expectations related to low-dose computed tomography scans for lung cancer screening to facility primary care providers.

Date Issued
|
Report Number
22-03909-19
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Topics: Information Technology and Security

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No. 1
Open Recommendation Image, Square
to Information and Technology (OIT)

Develop and implement a strategy with milestones for identifying all VA websites, confirm their inclusion in VA’s Web Registry as the current system designated by policy, and certify the accuracy of entries annually or as changes occur.

No. 2
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to Information and Technology (OIT)

Establish a mechanism for web communication offices across VA to enforce the implementation of VA Handbook 6102 related to Section 508 compliance.

No. 3
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to Information and Technology (OIT)

Coordinate with VA under secretaries and other assistant secretaries to ensure system owners are educated on VA Directive 6221 and its accompanying handbook requirements to request accessibility audits.

No. 4
Open Recommendation Image, Square
to Information and Technology (OIT)

Institute a mechanism to ensure information technology system accessibility designations are accurate in the VA Systems Inventory.

No. 5
Open Recommendation Image, Square
to Information and Technology (OIT)

Update, recertify, and republish VA Directives 6221 (accessible information and communications technology) and 6404 (systems inventory).

No. 6
Open Recommendation Image, Square
to Public and Intergovernmental Affairs (OPIA)

Update, recertify, and publish VA Directive 6515 (use of web-based collaboration technologies).